Automatic Exchange of Information Individual Self-Certification Form

INDIVIDUAL SELF-CERTIFICATION FORM

GRP-Ind.SC–D02D05M18A 2/4

Individual Self-Certification Form

This self-certification form is collected to comply with existing and any future legislation enacted by any jurisdiction

that provides for or is intended to secure the exchange of information (including, without limitation, under US FATCA

and related Intergovernmental Agreements (“IGA”), the OECD Common Reporting Standard for Automatic Exchange

of Financial Account Information (“CRS”) including the EU Directive 2011/16/EU on Administrative Cooperation in the

field of Taxation, as amended (“EU DAC”), or any other jurisdiction's legislation which is similar in effect to any of the

above), any official interpretations or guidance thereof, or any law or regulations implementing an

intergovernmental approach thereto, or any agreements made pursuant to the implementation of the foregoing, in

each case as enacted, made, amended or replaced from time to time.

US FATCA, CRS, EU DAC, applicable laws, regulations and/or guidance notes, are together referred to as the

Automatic Exchange of Information (“AEOI”) regimes.1

Please seek professional advice when completing this form.

Type directly into this form and return a signed copy.

1. Individual Identification2

First Name

Last Name

Date of birth (DD/MM/YYYY)

Place and country of birth

Country of citizenship If more than one, state all

Residential address Do not use a P.O. box or in-care-of address

Address

City / Town

State / Province Postal Code

Country

Mailing address If different from above

Address

City / Town

State / Province Postal Code

Country

1 For further information on the Automatic Exchange of Information, refer to:

CRS: http://www.oecd.org/tax/automatic-exchange/common-reporting-standard

FATCA: https://www.irs.gov/businesses/corporations/foreign-account-tax-compliance-act-fatca

EU DAC 2: http://ec.europa.eu/taxation_customs/taxation/tax_cooperation/mutual_assistance/direct_tax_directive/index_en.htm

For accounts in Irish FIs, refer to : http://www.revenue.ie/en/companies-and-charities/international-tax/aeoi/what-is-aeoi.aspx

2 For Citco use only:

C&T: Individual ViewPoint Number:

CB: Account Number:

INDIVIDUAL SELF-CERTIFICATION FORM

GRP-Ind.SC–D02D05M18A 3/4

2. Declaration of Tax Residence

I hereby confirm that I am, for tax purposes, resident in the following countries.

When the Individual is US citizen/US passport holder and/or resident in the US for tax purposes (green card holder or

resident under the substantial presence test3), an IRS form W-9 must be completed and attached.

If the Individual is no longer a US citizen, the Individual must provide a certificate of loss of nationality of the United

States and a copy of the foreign passport.

Country(ies) of Tax Residence Tax Reference Number (“TIN”)4 or functional equivalent

3. Declaration and Undertakings

I declare that the information provided in this form is, to the best of my knowledge and belief,

accurate and complete. I understand that the recipient is responsible for processing the information

contained in this form (including personal data). I undertake to advise the recipient promptly and

provide an updated Self- Certification form within 30 days where any change in circumstances

occurs, which causes any of the information contained in this form to be inaccurate or incomplete. I

understand that I am required to reply to each information request sent to me by the recipient and

that failure to do so may have a negative impact on the reporting of my information, such as

potentially reporting to the wrong foreign tax authority.

Where legally obliged to do so, I hereby consent to the recipient sharing the information contained

in this form with the relevant tax authorities pursuant to international agreements and domestic

laws under the AEOI regimes. I understand that the recipient and/or the tax authorities may

exchange this information, along with other information such as account balances or value at year

end, and where relevant, certain payments made with respect to the account during the calendar

year, with tax authorities in other jurisdictions. I understand that I have the right to access the

information that relates to me and which is reported to the relevant tax authorities and I have the

right to rectify this information.

3 For further information on US tax residency for non-US citizens, refer to the Publication 519 in the IRS website:

https://www.irs.gov/publications/p519/ch01.html

4 Overview of the Tax Identification Numbers domestic rules:

http://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers/

INDIVIDUAL SELF-CERTIFICATION FORM

GRP-Ind.SC–D02D05M18A 4/4

I expressly acknowledge, agree and allow the Citco Group of Companies (Citco)5 to store the

information contained in this form on a centralised electronic database at secure sites possibly

located outside my tax residence jurisdiction(s), and in respect of which I agree that:

a) the information contained in this form may be made available to employees of Citco and any of

its Affiliates (whether or not outside my tax residence jurisdiction(s)); and

b) Citco or any other of its Affiliates (whether or not outside my tax residence jurisdiction(s)) shall

be entitled to use the information contained in this form to enable a classification under any

law, regulatory or other governmental enactment (e.g. foreign tax compliance purposes) and to

carry out any necessary registration and compliance as prescribed by such law, regulations or

governmental enactment; and

c) this may imply a transfer of information to jurisdictions where the level of data protection may

not be as high as in the jurisdiction(s) noted in Section 2 above.

For further information regarding Citco’s privacy policy, refer to: https://citco.com/footer/privacy-policy/

Complete Information

Print name of signer

Capacity in which acting (if form is not signed by the

individual/ Account Holder)

Date (DD/MM/YYYY)

Sign Here

Authorized Signature

©The Citco Group Limited, May 2018

5 The Citco Group Limited is the indirect parent of a network of independent companies. The Citco Group Limited provides no client services. Such

services are provided solely by the independent companies within the Citco group of companies (hereinafter, the “Citco group of companies”) in their

respective geographic areas. The Citco Group Limited and the Citco group of companies are legally distinct and separate entities. They are not, and

nothing contained herein shall be construed to place these entities in the relationship of agents, partners or joint venturers. Neither The Citco Group

Limited nor any individual company within the Citco group of companies has any authority (actual, apparent, implied or otherwise) to obligate or bind

The Citco Group Limited in any manner whatsoever.